Endoscopic suturing
Special Case on Reflux Esophagitis.

Video Endoscopic Sequence 1 of 32.

  Special Case on Reflux Esophagitis.

We consider this clinical case a very special one since we have perform several technical novelties on diagnostic and therapeutical endoscopy, which can be seen in these sequence; many of them have not been found in the medical literature, therefore we believe to be the originators and first practitioners of these novelties. One important think about this case is that it give us a new and useful experience, opening up to us new and unlimited diagnostic and therapeutics possibilities.

This 83 year old male patient , who has suffers of
 
long-standing gastroesophagic reflux disease (GERD).
Presented with esophageal stenosis with complete lumen
obstrution



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Special Case on Reflux Esophagitis.

Video Endoscopic Sequence 2 of 32.

The image display the Foley´s Catheter into the stomach.

It began has a progressive dysphagia. At first, he was under care by another gastroenterologist, who after failing to dilatate the esophagus, referred the patient to surgery, where he got a Foley's catheter for Percutaneous feeding. (surgical gastrostomy).

Due to this way of feeding, the patient suffers some psychological distress. After three moths of having the catheter, his family decided to look for a different opinion and came to us, where we offered to practice a balloon hydrostatic dilatation.


Retrograde endoscopic lumen identification and dilation.

Video Endoscopic Sequence 3 of 32.

  Special Case on Reflux Esophagitis.

Retrograde endoscopic lumen identification and dilation.

The image as well as the video clip display the thin endoscope of 5.9 mm, which is passed through the gastrostomy fistula.

After the esophagus has been dilated, we performed a retrograde transfistula endoscopy from the wall of the stomach all the way through the superior esophageal sphincter

Retrograde view from trasfistula endoscopy.

Video Endoscopic Sequence 4 of 32.

Retrograde view from trasfistula endoscopy.

Retrograde endoscopic lumen identification and dilation is a useful method to reestablish alimentary tract patency, thereby avoiding surgical interventiont.

The image as well as the video clip display, the gastric cardias with complete stenosis and fibrin which occluded completely the esophageal lumen.



Retrograde view from trasfistula endoscopy.

Video Endoscopic Sequence 5 of 32.

Retrograde view from trasfistula endoscopy.

Retrograde access was obtained by balloon dilation of gastrostomy tract, and an endoscope was passed to the area of stricture. Antegrade and retrograde endoscopy were performed simultaneously. An endoscope was passed either retrograde or antegrade under direct endoscopic visualization.

Image view of transfitula retrograde endoscopy. The
hydrostatic balloon was inserted by the mouth and
inspected with a magnifying endoscopes.

The image and the video clip of esophageal dilation with
hydrostatic balloon.

Hydrostatic Balloon which is dilating the cardias, esophagus view.

Video Endoscopic Sequence 6 of 32.

Hydrostatic Balloon which is dilating the cardias, esophagus view.

The part of the esophagus that was dilated, patient has a hiatal hernia.

Video Endoscopic Sequence 7 of 32.

The part of the esophagus that was dilated, patient has a hiatal hernia.

The image and the video clip was obtained from the gastric
camera with endoscope introduced by the fistula of
gastrostomy.

Retrograde endoscopic lumen identification and dilation is
an option to reestablish lumen patency of completely
occlusive esophageal strictures.

Another image and video clip of the fistula of gastrostomy where was introduced the endoscope which passed throughout the esophagus and inspected by the mouth.

Video Endoscopic Sequence 8 of 32.

Another image and video clip of the fistula of gastrostomy where was introduced the endoscope which passed throughout the esophagus and inspected by the mouth.

.



Superior Esophagic Sphincter seen by retrograde

Video Endoscopic Sequence 9 of 32.

Superior Esophagic Sphincter seen by retrograde endoscopy.

Observed through trans-fistula-gastrostomy retrograde endoscopy.

Nasopharynx. Observed through trans-fistula-gastrostomy retrograde

Video Endoscopic Sequence 10 de 32.

Nasopharynx.

Observed through trans-fistula-gastrostomy retrograde endoscopy.

We passed it from the mouth right to the back of the nose. After observing the nasopharynx, the endoscope was passed through the mouth.

This image and video clip is not usually observed in normal With this possibility give us, an unlimited therapeutical approach alone or together with the otorhinolaryngologist.


Now the endoscope is seen advanced throughout the mout

Video Endoscopic Sequence 11 of 32.

Now the endoscope is seen advanced throughout the mouth

Personally, I had always wanted to perform an endoscopy in retroflexion maneuver in the esophagus and to take out the endoscope per mouth , but I was afraid of causing a spasm of the larynx.

These retroflexion maneuvers are sometimes very important.

 







The endoscope which is inserted through the gastrostomy fistula is observed and has been advanced through the upper esophageal sphincter and and the endoscope is advanced out of the mouth.

Video Endoscopic Sequence 12 of 32.

The endoscope which is inserted through the gastrostomy fistula is observed and has been advanced through the upper esophageal sphincter and and the endoscope is advanced out of the mouth.

The flexibility of the thin endoscope is observed.


Download the video clip by clicking on the image.




















The endoscope was introduce through the nostrils observing the oropharynx.

Video Endoscopic Sequence 13 of 32.

The endoscope was introduce through the nostrils observing the oropharynx.

Then we have performed another technical novelty, a retrograde maneuver, from the Gastrostomy- fistula to the superior esophageal sphincter, the endoscope was introduce through the nostrils observing the oropharynx; we have introduced another endoscope into the esophagus.

 




 

In order to perform a therapeutical approach, we had the idea of using two endoscopes: one from the fistula and the other from the mouth, one following the other, facing each other

Video Endoscopic Sequence 14 of 32.

Withdrawal of the endoscope.

In this video clip it can be observed the return of the thin
endoscope, followed by an magnifying endoscope.

In order to perform a therapeutical approach, we had the idea of using two endoscopes: one from the fistula and the other from the mouth, one following the other, facing each other


 

 

The thin endoscope is withdrawn from the route

Video Endoscopic Sequence 15 of 32.

The thin endoscope is withdrawn from the route trans- fistula and is observed with the second endoscope.

observe now the other endoscope, the thicker one,

Video Endoscopic Sequence 16 of 32.

Image obtain with other endoscope via trans-fistula.

We observe now the other endoscope, the thicker one,
which was introduced by the mouth.




Intraluminal Face to Face Endoscopes

Video Endoscopic Sequence 17 of 32.

 Intraluminal “Face to Face Endoscopes"

In this animation hypothesize the multiple forms in this way of therapeutic endoscopy that could be used through two “face to face endoscopes”. Using the channels of biopsies can be combined different limitless therapeutic resources.


Download the animation by clicking on the image.

Retrograde suturing of the cardias.(Retrograde Gastroplicature).

Video Endoscopic Sequence 18 of 32.

Retrograde suturing of the cardias.(Retrograde Gastroplicature).

An over-tube was placed to be able to pass our rigid and maleables clamps.

Now we are ready to perform another technical novelty. A Trans-Gastric-Trasfistula post Gastrostomy, Retrograde suturing of the cardias.(Retrograde Gastroplicature).

A semicircular surgical needle with nylon thread is

Video Endoscopic Sequence 19 of 32.

A semicircular surgical needle with nylon thread is introduced through the over-tube helped with an object specially designed of malleable consistency with a magnet in the tip.

The passage of the semicircular needle with its respective

Video Endoscopic Sequence 20 of 32.

The passage of the semicircular needle with its respective nylon is observed, also are observed wires in form of spirals of the over-tube.

Endoscopic image obtained from the gastric camera by the endoscope inserted through the gastrostomy fistula.

The malleable instrument that it contains a magnet it helps

Video Endoscopic Sequence 21 of 32.

The malleable instrument that it contains a magnet it helps the passage of the semicircular surgical needle through the over-tube.

A modified laparoscopic needle holder is observed

Video Endoscopic Sequence 22 of 32.

A modified laparoscopic needle holder is observed.

Due to doubles between the over-tube and the injuries it was necessary to replace the malleable instrument by the needle holder which has better resistance to manipulate the needle in the passage to the gastric camera.





A modified laparoscopic needle holder.

Video Endoscopic Sequence 23 of 32.

 A modified laparoscopic needle holder.

In the working table a needle holder is observed which previous was enlarged from 30 cm to 70 cm. We used this modified laparoscopic needle holder to perform the stitches.




The neddle holder is introduced throughout the fistula.

Video Endoscopic Sequence 24 of 32.

The neddle holder is introduced throughout the fistula.

We proceeded to perform the stitches and our new

Video Endoscopic Sequence 25 of 32.

We proceeded to perform the stitches and our new technique. And with the mouth-esophagus-stomach endoscopy in retroflexion the procedure is observed.





And by the same maneuver we finished the gastroplicature.

Video Endoscopic Sequence 26 of 32.

And by the same maneuver we finished the gastroplicature.

 

In this video image it is observed the joint of two tissues,

Video Endoscopic Sequence 27 of 32.

In this video image it is observed the joint of two tissues,
which will be knotted.

The semicircular needle is withdrawn throughout the over-tube.

Video Endoscopic Sequence 28 of 32.

The semicircular needle is withdrawn throughout the over-tube.

Withdrawal of the semicircular surgical needle throughout

Video Endoscopic Sequence 29 of 32.

Withdrawal of the semicircular surgical needle throughout the mouth.

Due to the protection of the over-tube there is no dangerof injuries that could be caused by the needle.

 





Video Endoscopic Sequence 30 of 32.

Flexible Ti-Knot Device.

The flexible Ti-Knot Device will be use to place the titanium clip throughout 2 treads to perform the knot.


Endoscopic Suture

Video Endoscopic Sequence 31 of 32.

The flexible Ti-Knot Device is being passed to the over-tube to will perform the knot.

The gastroplicature was finished.

Video Endoscopic Sequence 32 of 32.

The gastroplicature was finished.

(Retrograde Gastroplicature).

A Trans-Gastric-Trasfistula post Gastrostomy, Retrograde suturing of the cardias.
The flexible Ti-Knot Device has been placed the titanium clip performing the knot

The patient has been stable since that day.

This case opening up to us new and unlimited diagnostic and therapeutics possibilities to be performed in a near future with our patients.

 



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